Marine Safety Investigation Report - Bahamas Maritime Authority · 2021. 3. 22. · Irenes Rose – Marine Safety Investigation Report 7 At 17:45, the chief engineer informed the

Irenes Rose – Marine Safety Investigation Report

Marine Safety Investigation

Report into a crew fatality on Irenes Rose on

08 February 2020


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The Bahamas conducts marine safety or other

investigations on ships flying the flag of the

Commonwealth of the Bahamas in accordance

with the obligations set forth in International

Conventions to which The Bahamas is a Party. In

accordance with the IMO Casualty Investigation

Code, mandated by the International

Convention for the Safety of Life at Sea (SOLAS)

Regulation XI-1/6, investigations have the

objective of preventing marine casualties and

marine incidents in the future and do not seek

to apportion blame or determine liability. It should be noted that the Bahamas Merchant Shipping Act, Para 170 (2) requires officers of a ship involved in an accident to answer an Inspector’s questions fully and truly. If the contents of a report were subsequently submitted as evidence in court proceedings relating to an accident this could offend the principle that a person cannot be required to give evidence against themselves. The Bahamas Maritime Authority makes this report available to any interested individuals, organizations, agencies or States on the strict understanding that it will not be used as evidence in any legal proceedings anywhere in the world. You must re-use it accurately and not in a misleading context. Any material used must contain the title of the source publication and where we have identified any third-party copyright material you will need to obtain permission from the copyright holders concerned.

Date of Issue: 19 March 2021 Bahamas Maritime Authority 120 Old Broad Street LONDON EC2N 1AR United Kingdom


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Contents

1. Summary ___________________________________________ 1

2. Factual Information ________________________________ 2

3. Analysis ____________________________________________ 8

4. Conclusions _______________________________________ 13

5. Lessons to be learned _____________________________ 14

6. Actions taken _____________________________________ 15

7. Recommendations ________________________________ 16

8. Glossary and Definitions __________________________ 17

Appendices ______________________________________________ 18


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1. Summary

Due to restrictions imposed as a result of the coronavirus pandemic, the BMA investigation team could not travel to the vessel to gather evidence and conduct interviews. Therefore, this investigation was conducted following the hierarchy of controls recognised by IMO Circular Letter No.4204/Add.16 establishing effective safety control measures and reducing the risk to personnel. The evidence, including the witness testimonies and images used for the purpose of this investigation, was provided by Tsakos Conbulk Services (TCB) Ltd.

What happened Occupational fatality of a crew member while he was working inside the main engine crankcase during a planned engine overhaul. Whilst replacing the main engine piston, the piston lifting tool was released out of sequence, causing the piston to drop inside the crankcase on to the crew member.

Why it happened Due to ineffective communication, lack of effective supervision and non-compliance with the manufacturer's instructions, the piston lifting tool was released, causing the piston to drop inside the crankcase on to the crew member.

What can we learn While carrying out any high-risk operation onboard, it is extremely vital to follow the manufacturer's instructions, adequately identify the associated hazards to establish proper safeguards, review all the identified risk and risk control measures in a risk assessment (RA) and effectively establish communication between all the parties involved.

http://www.imo.org/en/MediaCentre/HotTopics/Documents/COVID%20CL%204204%20adds/Circular%20Letter%20No.4204-Add.16%20-%20Coronavirus%20(Covid%2019)%20-%20Covid-19%20Related%20Guidelines%20For%20Ensuring%20A%20Safe%20Shipboard.pdf


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2. Factual Information Irenes Rose Vessel Type Container Flag Bahamas

Owner Seany Shiptrade Corporation

Manager Tsakos Conbulk Services (TCB) Ltd.

Classification Society Nippon Kaiji Kyokai Gross/Net

Tonnage 27104/11856

Built 2007 Propulsion Single propeller

IMO No. Callsign Length overall Breadth Depth

9363417 C6DU4 199.93m 32.20m 16.60m

Last BMA Inspection Last PSC Inspection

Carried out in Inchon, South Korea, on 30 July 2019. One deficiency identified related to the PSC deficiency was not reported as per BMA bulletin no. 85.

Carried out in Shanghai on 18 November 2019. Five deficiencies were noted. None of the deficiencies were related to this incident.


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Crew details

Rank/Role on board

Oiler A (deceased crew member)

Master Chief Engineer

Second Engineer

Third Engineer

Qualification

Able Seafarer Engine STCW III/5

Master STCW II/2 and GMDSS Radio operator IV/2

Chief Engineer STCW III/2

Second Engineer STCW III/2

Third Engineer STCW III/1

Certification Authority

Philippines Greece Greece Philippines Philippines

Nationality Filipino Greek Greek Filipino Filipino

Age 32 50 58 51 50

Time in rank with the Company

4 years 15 years 15 years 4 years 15 years

Time onboard 2 months and 19 days

3 months and 17 days




Environmental Conditions Wind

Direction Wind Force

Wave Height

Swell Height

Precipitation / Sky

Visibility Range

Light Conditions

SE 4 0.5 0 Clear 16Nm Daylight

Voyage Details

The vessel had completed the discharge operation at the port of Saigon, Vietnam, on 02 February 2020 and moved to the anchorage in Vung Tau, Vietnam.


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Narrative All times used in this report are UTC +7 unless otherwise stated. On 08 February 2020, at 08:00, while the vessel was at anchor in Vung Tau, Vietnam, the engine crew commenced the scheduled planned maintenance of the main engine involving the overhauling of the main engine piston no. 1. The removal of the piston and stuffing box was carried out by the crew successfully. After completing the overhaul of the removed piston and replacement of the piston rings, at 16:45, the crew commenced the mounting operation for putting back the piston using the piston lifting tool1.

Figure 1: Piston lifting tool

The second engineer was in charge of lowering the piston using the engine room crane. He was stationed at the upper platform near the cylinder head along with the two oilers assisting him with the operation. The third engineer was in charge of placing the stuffing box into position and was inside the crankcase along with the technician and oiler A (deceased crew member) assisting him to complete the task. The chief engineer was standing outside the crankcase at the lower platform supervising the whole operation. The second engineer and third engineer each had a personal portable VHF radio used to communicate the piston rod's position while the second engineer was operating the crane. The third engineer, technician and oiler A took about an hour to stow the stuffing box in its position. The chief engineer instructed the third engineer to tighten the stuffing box. Oiler A was assisting the third engineer to complete this task. After tightening the stuffing box, the chief engineer instructed the crew to clear all the tools, clean the surface and exit the crankcase. The third engineer left the crankcase first and went to the engine control room to drink water. The technician came out of the crankcase after removing the tools. Oiler A was still inside the crankcase to clean up the area.


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Figure 2: Position of crew members

1 The lifting tool has three claws: two stationary and one adjustable claw. The claws sit in the piston lifting grooves on the top of the piston.


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Figure 3: Position of chief engineer and technician

Figure 4: Position of oiler A (deceased crew member)

The third engineer returned to the lower platform and the chief engineer instructed him to turn the engine using the turning gear. At this time, the piston lifting tool was released by the second engineer and the engine crew heard a loud noise of the piston dropping inside the crankcase. Subsequently, oiler A was found, injured and unresponsive, in the sump tank of the main engine.


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At 17:45, the chief engineer informed the master about the accident. Five minutes later, the master arrived in the engine room and oiler A was declared deceased. At 19:30, the deceased oiler was transferred to the vessel's hospital.


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3. Analysis

The purpose of the analysis is to determine the contributory causes and circumstances of the casualty as a basis for making recommendations to prevent similar casualties occurring in the future.

Engine manufacturer's instruction manual The vessel had a 7S70MC-C2 Man B&W main engine, manufactured by Hitachi Zosen. The engine manufacturer provided a step by step instruction manual that included the chronological steps with diagrams for dismantling, overhauling and mounting of a piston. The manual was not reviewed before starting the work activity and was not discussed at any time during the piston removal, overhauling and mounting process. The manual identified 16 steps to complete the piston mounting operation (see Appendix 1). The engine crew completed the initial steps of mounting the piston, which corresponded to the first seven steps of the manual. However, step 8 and step 9 were not followed. Step 8 required the crosshead to be turned nearly to the top dead centre (TDC) while checking that the guide ring of the crosshead enters the centre hole in the piston rod.

Figure 5: Diagram from the main engine manufacturer’s manual for step 8 of piston mounting

2 Engine type designation for 7S70MC-C engine: 7-Number of cylinders, S-Super long strokes, 70-Diameter of piston in cm, M-Engine performance, C-Camshaft controlled, C-Compact design.


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Figure 6: Centre hole of piston and crosshead guide ring

The crosshead was not turned to near the TDC position for the mounting process of the piston. Step 9 of the manual required the piston to be fully turned to TDC to ensure that the piston rod is in full contact with the crosshead. The adjustable claw of the lifting tool then could be unscrewed and the lifting tool pulled free from the lifting groove in the piston ring. This step was not followed either and the crosshead was not turned to TDC for the piston rod to be in contact with the crosshead. The second engineer unscrewed the lifting tool's adjustable claw using a spanner and hammer to free the lifting tool from the lifting groove, leading the piston to be unsupported.

Figure 7: Diagram from the main engine manufacturer’s manual for step 9 of piston mounting

with parts labelled The chronological sequence of the instruction manual for further steps was also not followed. As the piston was lowered into the cylinder liner, the chief engineer instructed the third engineer to tighten the stuffing


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box and oiler A was assisting him to complete this task. This operation was carried out without turning the engine to TDC or completing instructions outlined under steps 8 and 9 of the manual.

Step number

Engine manufacturers instruction manual steps

Actual steps taken and issues identified

8 Turn the crosshead nearly to TDC while checking that the guide ring of the crosshead enters the centre hole in the piston rod.

Actions corresponding to step 10 and step 11 of the manual were carried out prior to the actions required as per step 8 and step 9. 9 After turning the piston fully to TDC and

ensuring that the piston rod has full contact with crosshead, unscrew the adjustable claw of the lifting tool and pull the lifting tool free from the lifting groove in the piston ring. Remove the lifting tool and the guide ring for piston insert.

10 Turn down and land the stuffing box on the stuffing box flange. Check that the holes in the stuffing box and stuffing box flange are correctly centred. Remove the distance pieces from the piston rod front.

11 Tighten down the piston rod stuffing box by means of the screws through the inner hole in the stuffing box flange.

Table 1: Chronological sequence of the instruction manual and issues identified

Inadequate hazard identification and risk assessment The hazards associated with a crew member being present inside the crankcase during the mounting operation of the piston were not identified in the existing RA before commencing the operation. The International Safety Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code) section 1.2.2.2 requires 'Safety management objectives of the Company should, inter alia; assess all identified risks to its ships, personnel and the environment and establish appropriate safeguards.' The Company's safety management system (SMS) had a risk management procedure for identifying the hazards and implement effective control measures to prevent any harm and reduce risk levels. The procedure stated: During work planning and prior to start a job/ operation, the RA Library Index should be reviewed, in order to check whether the particular job/ operation is included.

• If a relevant RA exists, then this RA must be reviewed, in order to confirm that it applies to the case and no additional hazards exist. In such a case records must be maintained in the RA log.

• If during the onboard review additional hazards will be identified the RA should be revised with the additional hazards and risk control measures and forwarded to the Company.

for approval, if the risk involved is High or Medium, for notification, if the risk involved is Low.


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The operation for piston overhauling was considered as routine job and risk assessment (RA) 'R2.7 main engine piston overhauling' was available in the RA library for the crew to use. The RA log was also updated, as per the Company's procedures.

Figure 8: Extract from RA log

The 'additional risk control measures' in the risk assessment required the crew to keep clear during lifting operation and to have close communication between the crane operator and officer guiding the piston removal operation. These control measures were included for lifting operations. However, there were no such hazards identified or risk control measures put in place or included in the risk assessment for the mounting operation.

Figure 9: Extract from risk assessment for main engine piston overhauling

The risk control measures also included the requirement for developing a plan for undertaking the work by taking the maker's manual into account. However, the maker's manual was not discussed prior to starting or during the operation. It could not be determined through the evidence obtained why one of the specified risk control measures was not incorporated within the safety discussion before or at any point during the task. This requirement as detailed within the existing RA, which was not applied on this occasion, resulted in the task being carried out without adequate risk control measures in place.

Figure 10: Extract from risk assessment for main engine piston overhauling


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Ineffective communication During the overhaul process, the third engineer and second engineer had personal portable VHF radios. While mounting the piston into the cylinder liner, the third engineer was inside the crankcase and was frequently communicating with the second engineer handling the crane to lower the piston. From the testimonies of the third engineer and second engineer, it was concluded that the communication between both crew members was ineffective and it led the second engineer to believe that the lowering operation of the piston was completed and he could remove the lifting tool from the piston. Subsequently, he started removing the lifting tool using a spanner and hammer. Once the lifting tool was released, the piston fell into the crankcase while oiler A was still inside. The chief engineer was the supervisor of the whole overhaul operation. He did not have a personal portable VHF radio with him. Although the vessel's working language was English, the communication between the third engineer and second engineer was in Tagalog3. The chief engineer, who was a Greek national, did not understand the conversation to verify any action taken by the third engineer or the second engineer.

3 Language spoken in the Philippines


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4. Conclusions

• A crew member died while working inside the main engine crankcase when the piston fell on him. The piston lifting tool was released during the piston mounting operation, leading the piston to drop inside the crankcase.

• As part of the existing RA, taking the engine manufacturer's instruction manual into account while planning the operation was required. However, the manual was not discussed or followed by the crew members at any time during the operation.

• No hazards related to the crew member being inside the crankcase during the mounting

operation of the piston were identified in the RA. • The communication between the third engineer and the second engineer was ineffective and

led the second engineer to believe that the lowering operation of the piston was complete and subsequently, he removed the piston lifting tool using a spanner and hammer.

• The chief engineer was the supervisor of the whole operation. However, he did not have any

portable radio with him while the task was being carried out. Further, the communication between the second engineer and the third engineer was in Tagalog and chief engineer did not understand the language to verify any action taken by the two engineers.


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5. Lessons to be learned

• Before carrying out any high-risk operation, such as overhauling and maintenance of the main engine, the manufacturer's instructions must be discussed and incorporated in the planning of the operation.

• The crew involved in the operation must understand and follow the manufacturer's instructions at all times.

• A thorough review of the risk assessments for any high-risk operation must be carried out to identify the hazards and risks associated with every stage of the operation and to implement appropriate safeguards to eliminate those risks.

• Reviewing all the risk and control measures in a risk assessment are vital for the effectiveness

of the risk management process onboard. • Effective communication should be established while carrying out any operation onboard. The

supervisor of the operation and all involved crew members should be equipped with the appropriate communication devices and communicate in the vessel's working language throughout the operation.


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6. Actions taken

Actions taken by the Company: • The Company had issued a fleet-wide alert regarding the accident, highlighting the importance

of the main causes of the incident. The same alert had been added to the senior officers' briefing process prior to joining the vessel.

• The Company had enhanced instructions to all personnel involved in similar tasks to reinforce that during planning meetings, all the necessary issues, points of concern and applicable hazards are discussed thoroughly, including manufacturers' special precautions and instructions, fulfilling the obligation contained within recommendation 7.1.

• The Company's risk assessment for the specific overhauling work activity was further amended to incorporate the additional hazards and risk control measures that were revealed during the company's investigation.

• The Company shared the lessons learned/Incident investigation with the manning agencies to enhance further crew awareness for the causes and lessons learned.

• A safety campaign was launched with the aim to further promote and stimulate positive interventions and the significant importance of the Stop Work Authority and hazard identification when performing any task onboard, fulfilling the obligation contained within recommendation 7.2. The name of the campaign was "I AM SAFETY" intended to remind all that safety is everybody's duty and responsibility.


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7. Recommendations

Recommendation for the Company: • Consider updating the Company's procedures to highlight the importance of reviewing and

following the manufacturer's instructions for any high-risk operation.

• Provide additional training to the crew members to improve the identification of hazards and conducting job-specific risk assessments.

• Ensure an effective communication plan is established before the commencement of any

operation. All the crew members involved shall be equipped with appropriate communication devices and use the vessel's working language to ensure effective and thorough understanding of safety critical matters.


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8. Glossary and Definitions

BMA The Bahamas Maritime Authority

Company Company means the owner of the ship or any other organization or person such as the manager, or the bareboat charterer, who has assumed the responsibility for operation of the ship from the owner of the ship and who on assuming such responsibility has agreed to take over all the duties and responsibilities imposed by the International Safety Management Code.

m Meters

nm Nautical miles

No. Number

RA Risk assessment

SMS Safety Management System

TDC Top dead centre

VHF Very High Frequency


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Appendices

Appendix 1: Engine manufacture's instruction manual for piston mounting


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